P - 46719Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ' I'" 1 i' I
SITE ADDRESS � a
THIS APPLICt1NT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
P�RMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL AFPLICATION
CITY OF FRIDLEY
EFFECTIVE i-1-2011
YOUR E-MAII,
�'1`� �L
❑ OWNER
NAME:
STATE LICENSE #
PxorrE / �v.5 � / � � '/ y--7
�3INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
0 BASEMENf FINISH �ROOF
❑ DECK � SIDING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMF,NT
ROOFING
NtJMBER OF SQUARES �
s�
PROP03ID SIZE:
PROPOSED HEIGHT:
�
CERT
r�c / (o .� �
SIZE
HOME CONSTRUCTION ❑ ADDITION
fTENANCE/REPAIIt ❑ REMODELING
=g-� � � �
--�
LENGTH WID'�
❑ HOUSE ONLY
$IiOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TTLE
❑ OTHIIt
Permit N�%���
Received By �
Dat�I�' ' , '�
tcti, u
v� . Gevri
o�
STA'! ti/ ✓/-/ ZIP .7-� L"l J' oZ.
� �r-- a i'f3 �- �
�i� �Z-k- IL STATE�IP SS i,/3�
� Jr "- lo � s�
FT
BASEMEN'I' REMO ELING SUBMIT•
1. Existing F7oor Plan
2. Proposed floor plaa
3. List of slructural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl p��t ADDITIONS_ Bc PORCT-t1�S �iTRMiT•
����� O Trim 1. Site Plan/Survey showing tlae existing structures
❑ Other
❑ Fascia and proposed project.
WIIVDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS �• ��'�Y Calculations
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF FOR WINDQWS - PROVIDE U-VALUE AND
OPENING CHANGES � MANUFACTURE STICKER ON WINDOW,
TYPE OF WINDOW TO BE INSTALLED NUMI3ER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'AT 1 7 r.,,, �,. r., ..,,:..�. ,� ,�- �SING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ -�I1�1.�.5-
$ j� �+ 1
$ (
$
$
$
$
$
$
I hereby apply for a buiiding p �m
conformance with the ordinances an�
permit but only an application for a
approved plan in the case of all, �. Qrk
SIGNATURE OF APPLICANf (:.� /(,a.
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Ma_ke checks pa_yable to: Citv of Fridtev Atr��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNfIL PROCESSED
it and I acknowledge that the information above is complete and accurate; that the work will be in
codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
't and work is not to start without a permit on site; that the work will be in accordance with the
w'c r uires eview and approval of pla�s�
PRINT NAME Nt � 1-�-l� � d y+�tsS n.a'►'F: //-/ ti'� /l